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Evaluation of the Level of Awareness of the Dangers Associated With Anemia in Pregnancy




2.1       Conceptual Review

2.1.1    Concept of Anemia

Anemia is a frequent companion to pregnancy due to the relatively larger plasma volume expansion compared to red blood cells. Proper transport of oxygen from the maternal blood to fetal circulation is essential during childbirth to give birth to a viable baby and also saludable. Maternal morbidity is also affected by the degree of anemia that occurs during pregnancy. Therefore, anemia may precede conception, which is often aggravated by pregnancy, and occupational accidents may sustain it (Lawson and Steward, 2014). Therefore, it is an important public health issue that requires the most attention, as pregnancy and childbirth around the world are daily events and, in particular, we need to lower our high maternal mortality rate.

The word anemia connotes a deficiency in the number of red blood cells or hemoglobin content that results in a diminished ability to transport oxygen from the blood, causing unusual fatigue that generates pallor, respiratory distress and lack of energy. Anemia can be relative or absolute. Relative anemia occurs during pregnancy (Bolton et al., 2018). Absolute anemia implies a true decrease in the mass of red blood cells. The cells are produced in the bone marrow and have a life expectancy of approximately four months (120 days) (Bolton et al., 2018). The body needs iron, vitamin B12 and folic acid to produce red blood cells. Absence of one or more of these ingredients causes anemia.

Red blood cells are the circulating cells in the blood plasma, which give the blood its red color. Through its pumping action, the heart drives blood through the arteries through the body. Red cells absorb oxygen into the lungs and transport it to all body cells. The cells use oxygen to drive the burning of sugars and fats that produce the body’s energy. In this process called oxidation, carbon dioxide is produced as a waste product. It binds to red blood cells that have released their oxygen load. Carbon dioxide is then transported back to the lungs by the blood in the veins, where it is exchanged by breathing for fresh oxygen (Bolton et al., 2018).

The recommendation of the World Health Organization (WHO) is that anemia occurs in pregnancy when the value of the mass of hemoglobin (Hb) circulating in the peripheral blood circulating 11 g/dl (PCV 33%) or less but in developing countries it is generally accepted That anemia is present when the concentration of Hb is less than 10 g/dl or hematocrit (PCV) less than 30% (Akin Agboola 2018). Anemia ranges from mild to severe to moderate and WHO estimates hemoglobin levels for each of these degrees of anemia in pregnancy to be between 9.0 and 10.9 g/dl as mild anemia; 7-8.9 g/dl as moderate anemia and <7.0 g/dl as severe anemia (WHO, 2019).


Every year more than 500,000 women die from pregnancy-related causes, 99% of them from developing countries. Estimates of maternal mortality from anemia range from 34 / 100,000 live births in Nigeria to 194 / 100,000 in Pakistan. Anemia is estimated to account for 17 to 46% of maternal deaths when combined with obstetric hemorrhage. The incidence of anemia in pregnancy varies from place to place, even within a country depending on socioeconomic status and level of development (Nynke van des Broeka 2018). It is between 5 and 50% of pregnant women in the tropics participating in prenatal clinics anemic compared to the prevalence rate of 2% in the developed world (Tropical Journal, 2018) claims that.

It is estimated that more than half of pregnant women in the world have hemoglobin levels indicative of anemia. In industrialized countries, anemia occurs in pregnancy in less than 20% of women. However, this is important for public health (> 10%). The quotas published for developing countries vary between 35% and 72% for Africa, between 37% and 75% for Asia, and between 37% and 52% for Latin America. A retrospective study of normal pregnant women were registered in the prenatal unit of the University Hospital of the University of Nigeria (UNTH) Enugu showed that 40.4% of the study population was isemica (Hb <11 g) in reserve. The prevalence of anemia in the reserve increased significantly with increasing gestational age in the reserve (Cyril and Hycinth, 2017). Another study conducted in Gombe in northeastern Nigeria found a 51.8% prevalence of pregnancy anemia. The majority of these patients 67.4% were mildly anemic; 30.5% were moderately anemic; while only 2.1% had severe anemia (Bukar et al., 2019).

In West Africa, anemia in pregnancy is due to several causes, such as iron and folic acid deficiency, malaria and hookworm infestations, infections such as HIV and hemoglobinopathies. Pica has been identified as a risk factor for anemia in pregnancy (Adam et al., 2019). This could be applicable to this environment where one can easily access the special group kaolin clay in open markets (called “NZU” in Igbo language) and wish some pregnant women. Anemia is not only common; it is often severe. Published reports available, it is estimated that between 2 and 7% of pregnant women Hb has <7.0 g/dl, and probably between 15 and 20% has values ​​<8.0 g/dl. It is suggested that the prevalence of anemia may depend on the season, increase the link with the transmission of malaria in the rainy season, or increase food shortages associated with end-dry season. In 1993, the World Bank ranked anemia as the eighth leading cause of the disease among girls and young women of age in developing childbearing, although it is believed that anemia is less common in non-pregnant women (Nynke van des Broeka 2018).


2.1.2    Causes of Anemia in Pregnancy

Anemia in pregnancy is a major public health problem in developing countries. In sub-Saharan Africa, such anemia is widely recognized as a result of a lack of nutrients, especially iron deficiency (WHO, 2019). Women often become anemic during pregnancy as the need for iron and other vitamins increases due to the physiological burden of pregnancy. The inability to achieve the required levels of these substances due to malnutrition or infection leads to anemia. The mother has to increase her production of red blood cells and additionally the fetus and the placenta need their own supply of iron, which can only be obtained from the mother.

To have enough red blood cells for the fetus, the body begins to produce more red blood cells and plasma. It is estimated that the blood volume increases about 50% during pregnancy, although the amount of plasma is proportional older (Viteri, 2014). This causes a dilution of the blood that causes the hemoglobin to decrease. This is a normal process, with hemoglobin concentration at the lowest level between weeks 25 and 30 gestación (Bolton et al., 2018). The pregnant woman supplements need additional iron, and the best way to control this is a blood test called serum ferritin.

Anemia in pregnancy is often of multiple causes. Iron and folic acid deficiency are by far the most important etiological factors. The increased demand for these substances is exacerbated by multiple pregnancies, short birth rates, parasitic infections and helminth, which are common among black women. Malaria parasites, which cause the destruction of red blood cells, contribute significantly to the prevalence of anemia in a population. Hemoglobinopathies such as sickle cell disease contribute to the cause of anemia in Africa. The causes are explained below;

Iron deficiency: iron needs increase during pregnancy because the fetus demand and increased blood volume, especially in the last quarter, with up to 80% of the requirements for the third quarter. The total iron requirement during pregnancy is about 1000 mg (300 mg for the fetus, 50 mg for the placenta, 450 mg for an increased maternal red cell mass, and 240 mg for the continuous maternal loss of iron basal) (Hodges, 2019). Requirements during the first trimester are relatively small (about 0.8 mg per day), but significantly increase to 6.3 mg per day in the second and third trimesters. After childbirth and during breastfeeding, iron use decreases 1.31 mg/day, which is 0.24 for menstruating women (2.3 mg/day). Despite the increase in iron intake being less than the requirement, pregnancy, diet alone can do not cover increased demand. Therefore, the extra iron needs to be covered by the iron reserves of the body. Many women in developing countries start pregnancy with a reserve of depleted iron because of diets low in iron, but loss of chronic blood due to parasitic infections and frequent and tight pregnancies, without giving the body enough time to replenish your depleted reserves. It was estimated that in the absence of iron supplements, it can take up to two years to get back to the pre-pregnancy state of iron. The iron reserves in women of childbearing age continue to decline due to the loss of menstrual blood (Hodges, 2019).

The iron deficiency is mainly diet-related. There are two types of iron, heme and non-heme diets. Heme iron found in animal foods such as meat, fish, poultry and its bioavailability is high, with absorption of 20 to 30%. It absorbs about twenty-three times better than non-heme iron. Non-heme iron occurs in food of plant origin, especially in whole grain cereals, tubers, vegetables and legumes. A small amount of heme iron in the diet will actually absorb the absorption of non-heme iron and therefore the composition of the diet is an important factor for the amount of iron being absorbed. Its bioavailability is lower and is determined by the presence of enhancers and inhibitors consumed in the same food. The absorption enhancers non-heme iron are meat, poultry, fish and vitamin C. Meat, poultry and fish is thus doubly valuable, because not only do they provide a rich source of bioavailable iron, but they also enhance the absorption of non-heme. Iron in the rest of the meal included (Nynke van der Broeka 2018). Foods that are consumed in most African households have low levels of meat, vitamins and carbohydrates and high phytate, which inhibit iron absorption. Phytates in wheat and other cereals and even a small amount can significantly reduce the absorption of iron. In developing countries where meat consumption is low, vitamin C is the main enhancer of iron intake. The addition of only 50 mg of vitamin C to the diet cans double the iron intake. This amount of vitamin C can be provided by an orange, 20 g of papaya or mango or 100 g of raw cabbage. But always, malnutrition or prevalent malnutrition in many parts of the developing world due to socioeconomic disadvantage and sometimes taboos and superstitious ways of producing certain foods, such as vegetables too much. In addition to food derived from foods, iron can be exogenous and have its origin in the soil or in iron cooking vessels. This can greatly increase the iron content of any food.


Folate Deficiency: Folates are fat-soluble vitamins, light-sensitive and water-soluble, which are essential for the maturation of red blood cells (Hodges, 2019). Folates are found in almost all foods, but in the liver, yeast extract, vegetables, dark green leaves, yams, sweet potatoes, egg yolks, fish, legumes, nuts and fruits like the banana, the banana and the mangoes. Fresh foods rich in folate are available only during the harvest season is seasonal, so folate intake is also seasonal. Some important in developing countries, such as rice, cassava, millet, sorghum and corn staple foods are bad sources of folic acid. Folate deficiency anemia is characterized by abnormally large erythrocytes (megaloblastic anemia). Since folate is heat-labile, long cooking and reheating food repeatedly, which is a common practice in the third world, may be an important factor in the emergence of folate deficiency anemia factor. The requirement for folic acid during pregnancy has roughly doubled, especially during the third trimester and after childbirth (Hodges, 2019) and since body stores are limited to folate and it is likely that food intake is insufficient, anemia often develops as a result. Usually, there is a steady decline in the level of serum folate during pregnancy, especially among women of lower socioeconomic groups in multigravidae, smokers and women with twin pregnancies. Diseases associated with hemolysis, such as malaria and sickle cell disease, also increase the requirement for folic acid. Therefore, pregnant women are often at the same time deficient in malaria and folic acid. Studies show that malaria prophylaxis alone, without folic acid supplementation, reduces the incidence of megaloblastic anemia in primigravidae by 50%, while completely eliminating folic acid supplementation (Hodges, 2019).

Iron deficiency and folate, both nutritional origins tend to live together in the same subject. This should be taken into account since iron deficiency almost always coexists with the presence of megaloblastic anemia. There is evidence that folic acid supplementation administered to a mother at the time of conception reduces the incidence of neural tube defects in infants born to these mothers (WHO / UNICEF, 2019).


Malaria: In sub-Saharan Africa, the region most affected by malaria, it is estimated that malaria infection causes 400,000 cases of severe anemia of the mother year (WHO / UNICEF, 2019). This is one of the main causes of severe anemia during pregnancy. In areas of high transmission, women have acquired a level of immunity to malaria that disappears somewhat during pregnancy. It is a particular problem for women in their first and second pregnancy and for women who are HIV positive. Anemia-related malaria is caused by hemolysis of red blood cells, hypersplenism, (a condition characterized by an exaggeration of the inhibitory or destructive spleen function); Contribution to anemia in up to 25% of women who suffer from anemia during pregnancy. Therefore, protection against malaria by chemo and other control methods greatly reduce malaria morbidity and maternal mortality (WHO / UNICEF, 2019).


Sickle cell disease (SCD): Around 60 million people around the world suffer from sickle cells, of which 50 million live in Africa. People with a sickle cell trait (heterozygous) have minimal clinical problems, but homozygotes have SCD, leading to chronic hemolytic anemia. More than 100,000 babies are born each year with SCD, most of them in Africa (WHO / UNICEF, 2019). Anemia is an important feature of sickle cell disease (which is why the disease is commonly referred to as sickle cell anemia). Anemia is severe and can be exacerbated by sequestration of acute sickle cells or, more commonly, by “aplastic crisis” when the marrow slows hemopeya during acute infections. Folic acid and iron deficiency are often associated with SCD as the hemolytic process increases the need for these nutrients (WHO / UNICEF, 2019).


2.1.3    Management of Anemia

The purpose and objectives of treatment should be to restore hemoglobin levels and red blood cell levels to normal levels, and replenish iron stores to prevent further decline in hemoglobin levels, relieve symptoms associated with anemia, thereby improving quality of life (QoL) improved. If this cannot be achieved, an additional assessment should be considered. The large differences in the clinical scenarios require a number of measures. The beginning of treatment depends on the symptoms (fatigue, headache, shortness of breath and palpitations), the etiology and severity of anemia, comorbidity and possible side effects of the therapy.

Iron treatment: In iron deficiency without anemia, different approaches to iron replacement should be considered and discussed with the patient. If ADIs are likely to occur in patients, the monitoring frequency should be increased.

Oral Iron: Treating an underlying cause should prevent further iron loss, but all patients should receive iron supplements to correct anemia and replenish body stores. This is achieved in the simplest and most economical way with 200 mg iron sulphate twice daily (NMC, 2018). Lower doses may also be as effective and better tolerated and may be considered in patients who cannot tolerate conventional doses. The main factor for oral iron is comfort, not effectiveness. Oral iron may not be able to compensate for persistent blood loss. Oral iron supplements may be used if the absolute indications for intravenous iron therapy are not met. When oral iron is used, response and tolerability should be monitored and treatment switched to intravenous iron as needed. Side effects are usually related to the dose. Absorption and effectiveness are not greater when high doses are used. Do not prescribe more than 100 mg of elemental iron per day. Other iron compounds (for example, iron fumarate, iron gluconate) or formulations (iron suspensions) may also have better tolerability than iron sulfate (WHO, 2019).

Ascorbic acid (250-500 mg twice a day with the iron supplement) can improve iron absorption. It is recommended that oral iron be continued for up to three months after the iron deficiency correction so that the stores can be replenished (NMC, 2018). It is true that taking dietary iron decreases the side effects associated with GIT to some extent. However, the basic African diet consists of grains and cereals containing phytic acid. Phytate reduces the absorption of iron. The addition of vitamin C in medicine or nutrition improves iron absorption. Therefore, the timing of oral iron intake in relation to food should be considered in the treatment of cases. If the predictable increase in hemoglobin does not occur after oral iron therapy, you should find out the possible reasons. Some of the reasons include: incorrect diagnosis, malabsorption syndrome, and presence of chronic infection, loss of iron in the body, lack of patient compliance and ineffective release of iron from a given preparation.

Parenteral iron: The failure rate with oral iron therapy in pregnant women is very high due to gastrointestinal side effects, such as nausea, vomiting, diarrhea and abdominal pain. Sometimes pregnant women suffer from severe anemia after 30 to 32 weeks of gestation, and in these cases, time plays an important role in improving hemoglobin status. In such situations, parenteral iron therapy is indicated. Parental iron can be administered intramuscularly or intravenously (NMC, 2018).


2.2       Theoretical Review

Theory of planned behaviour

The theory of planned behaviour (TPB) is an extension of Theory of Reasoned Action (TRA) (Ajzan in Polit and Beck 2016). The concept was proposed by Icek Ajzan to improve the predictive power of the Theory of Reasoned Action (TRA) by inclOnitshang perceived behavioural control. Polit and Beck (2016) stated that TPB provides a framework for understanding people’s behaviour and its psychological determinants.

TPB consists of the following propositions:

  1. Behaviour that is volitional is determined by people’s intention to perform or not to perform behaviour.
  2. Intention to perform or not perform behaviour is determined by three factors – attitude toward the behavior which is the overall evaluation of performing the behavior; subjective norms which is perceived social pressure to perform or not to perform the behavior; and perceived behaviour control which are the self-efficacy beliefs and anticipated ease or difficulty of engaging in the behaviour.
  3. The relative importance of the three factors in influencing intention varies across behaviour and situation.

Application of the theory to the study

  1. Behaviour exhibited by pregnant women and mothers is determined by the intention of the woman to perform the behaviour. Thus women who know that seeking healthcare services from skilled health care providers at a timely period, will help in identification and proper management of any identified problem (such as anemia), will naturally book early for anenatal care (ANC) in a health facility under skilled care providers. This ensures that optimal wellness of mother and feotus will be maintained which will most likely result in positive pregnancy outcome. On the contrary when they believe that the unskilled birth attendants can render the same care with similar efficacy and at a lower cost, they will ignore the skilled health care providers’ services.
  2. Intention to perform or not to perform behaviour is determined by:

Overall evaluation: the overall evaluation a mother gives to the outcome of services provided by skilled health care providers will determine if the mother will seek health care services from skilled health care providers. In the developed world, most mothers rate high the outcome of services provided by skilled health care providers. Thus most mothers seek healthcare services from the skilled health care providers.

Subjective norms: the high rating of services provided by the skilled health care providers is further influenced by societal pressure. Positive societal pressure will further increase the urge in mothers to seek health care services from skilled health care providers.

The anticipated ease or difficulty of engaging in the behaviour: when mothers feel it will be difficult for them to access the skilled health care provider’s services because of distance or transportation means, they will quickly go to the unskilled provider. On the other hand, if the mothers feel the difficulty attached to accessing the skilled health care provider’s services is worth the outcome of care, they will make effort to access that care instead of going to the unskilled provider that is at their door step.

  1. The key determinant of maternal healthcare seeking behaviour is evaluation, accessibility to health care services and anticipated ease or difficulty in seeking care from skilled health care providers. Mothers who place high value on the services of skilled health care providers and who are educated or have peers that support the care by skilled providers, often seek health care from skilled health care provider.


2.3       Empirical review

Anemia is a disease caused by inappropriate dietary pattern of man and hence is a man-made disease. Childhood anemia predominantly occurs in preschoolers. It is a global health problem among developing nations and in the under privileged communities of the developing nations too. The main factor that attributes the problem is uncontrolled population and poorly utilized resources

World Health Organization (2016) estimated that globally, anemia affects 1.62 billion people (95% CI: 1.50–1.74 billion), which corresponds to 24.8% of the population (95% CI: 22.9–26.7%). The highest prevalence is in preschool-age children (47.4%, 95% CI: 45.7– 49.1), and the lowest prevalence is in men (12.7%, 95% CI: 8.6–16.9%). According to the latest report of WHO (2016) estimated roughly 43% of children have anemia globally which is corresponding to 273 million children (WHO, 2016).

The most common cause of childhood anemia is iron deficiency that occurs due to poor or inappropriate feeding practices. Iron is needed to form hemoglobin and is mostly stored in the body in the form of hemoglobin. About 30% of iron is stored as ferritin and hemosediderin in the bone marrow, spleen and liver. A person suffers from anemia when the body is unable to form enough red blood cells (Marilyn J, 2019; Niki L.Potts, 2014).

Arlappa et al. (2019) conducted a community based cross-sectional study on prevalence of anemia among 404 rural preschool children of Maharashtra, India by collecting finger prick blood samples for the estimation of haemoglobin and sociodemographic particulars. The result shows that 59.2 % of the rural pre-school children of Maharashtra were anaemic, and the prevalence was significantly (p<0.001) higher (76.5%) among 1-3-year children as compared to 53.6% in 4-5-year children (Arlappa et al., 2019).


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